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II/2b/2VUU 1J.bf VAX U001/001 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN .lOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/e3 <br /> G <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: ' y( ' BUSINESSIAGENCY: �,+'1G'XY iri SejAmer <br /> ADDRESS: _y�7T't �-/t ' 1 v`Q,�"1v'',;`J("�t ��J n citylstatolzip <br /> PHONE(1): 210 'YSO--D PHONE(2): FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Time:_I I ,4M <br /> (Ple86e allow 10 business days from data of application submittal-"Tentat/ve only-must be connrmad) <br /> 13 CHECK BOX TO EXPEDITE RE T-5 S FEE(CASH OV CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS AYS <br /> SIGNATURE OF APPLICANTG s DATE <br /> v <br /> Electronic Information: ❑ List[]Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street Y Street Nems Cie <br /> ES,NoIQ'`.� U 1 <br /> 2. S 5 <br /> n Nodbl No unit Unit <br /> 4. G�5 N . EI rpt to Sl Ui>n 6')l ,ua a5 Units <br /> 8 Unit 4 <br /> N. T /NO Ui' <br /> 7. N. I r u� <br /> U <br /> s <br /> 8. <br /> 9. <br /> Unit e <br /> 10. <br /> SpecMc Date Range of Information Requested:From to CL1 rrpa� <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERORouNn TANK(UST)CLEANUP SITE(LOP) HOUSING ABATEMENT SouO WASTE FACILITYfVEHICLE U/7 <br /> ef <br /> OTHER CLEANUP SITE(NoN-LOP) FOOD FACILITY WASTE TIRE l.t.I' I <br /> UNDERGROUND TANK(MONITORINOIREMOVAL)O( DOG KENNEL DAIRY .6F f/�✓? <br /> HAZARDOUS WASTE OENERATORa CHICKEN RANCH WASTEwATER TREATMENT PLANT o <br /> TIERED PERMITTED FACILITY t- MOMLJHOTEL PUMPER TRUCKIYARotCHEM TOILETS <br /> 0ATTOOIBODY PIERCINGd m <br /> O /SPA /� &,tAN O USE APPLICATION SITES <br /> MEDICAL WASTE FACILIT� OTHER(PLEASE SPECIFY) tall T-A CS <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 5:00 AM-5:00PM - EXCLUDING HOUDAY6 <br /> 1. List up to ten addresses in the space above. Select the type(s)of flies from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)484-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted—for additional assistance with Nle addresses,contact the EHD. Applications received atter <br /> 100 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant If any EHD files exist. An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file Is available. <br /> 4. Any file not returned In the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$105 deposit prior to review. <br /> EHD USE ONLY <br /> -2-0�/ l /IVA 0 <br /> l2- CVDaa3/5 q �,- <br /> EHD 48-05 eIU4108 PUBLIC RECORDS RELEASE APP FORM <br />